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The purpose of the data collection forms and questionnaires presented in this page is:

  • to collect information to document results on the indicators outlined in the logistical framework of the REACH Coaltion.
  • show progress in the implementation activities and achievement of the goals.

Not all the documents are provided in english and spanish. If you are interested in accessing any of these documents, simply click on the right column choosing the appropriate language (where available in both languages)

Note: You will need Adobe® Reader® to view the following files.

      English Version
Spanish Version
I. Introduction and General Overview      


II. REACH Logistical Framework

<open Eng>    
III. Diabetes Empowerment Education Progranm (DEEP) <open Eng> <open Spa>  

IV. DEEP Instruments		      
  Pre/Post Test Instruments      
    A.8 Diabetes Empowerment & Educational Program Consent <open Eng> <open Spa>  
    A.5 Authorization for Release of Medical Information <open Eng> <open Spa>  
    A.10 Access to health Care Questionnaire – Short Form <open Eng> <open Spa>  
    A.11a Diabetes Self Care Activities Questionnaire <open Eng> <open Spa>  
    A.12 Quality of Life Questionnaire <open Eng> <open Spa>  
    B.5 Diabetes Awareness Questionnaire <open Eng> <open Spa>  
    B.6 Workshop Evaluation (End of Class) <open Eng> <open Spa>  
 
Other DEEP Forms		      
    A.2 Referral for Diabetes Education <open Eng>    
    A.13 Patient/Participant Contract <open Eng>    
    A.14 Participant Tracking Form <open Eng>    
    A.15 Consent for relative interview <open Eng>    

V. General and Self-Care Center Forms		      
    Monthly Reporting Form <open Eng>    
    Brief Intake & Finger Stick Information Release Consent <open Eng> <open Spa>  
    A.1 Diabetes Brief Intake Tool <open Eng> <open Spa>  

VI. Provider/Quality of Care Instruments		      
    B.1 Letter of Introduction – Provider Training Survey <open Eng>    
    B.2 Provider Diabetes Questionnaire <open Eng>    
    B.3 Diabetes Training Registration & Profile <open Eng> <open Spa>  
    B.7 Educational Session Observation Form <open Eng>    

VII. Community Leader and Coalition Member Instruments		    
    C.1 Agency/Membership Profile <open Eng>    
    C.2 Individual Membership/Participant Profile <open Eng> <open Spa>  
    C.3 Coalition Effectiveness Questionnaire <open Eng> <open Spa>  
    C.4 Meeting Feed Back Form <open Eng>    
    D.6 Community Leader Interview Guide <open Eng>    
    D.8 Consent for Participating in a focus group <open Eng>    

 
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Last Update: May 3, 2007